CMS Provides Webinar: Section 111 Non-Group Health Plan (NGHP)

August 17, 2020 by Patrick Czuprynski 

On 8/13/2020, CMS provided a webinar and PowerPoint presentation to highlight and refresh stakeholders regarding certain aspects of Section 111 reporting and the recommendations outlined in the MMSEA Section 111 User Guide.

It is important to understand that CMS is using the carrier/self-insured (or their TPA) claims system reporting for conditional payment collections.  This means timely reporting of ORM and TPOC with specific diagnosis code reporting (ICD system) is paramount to this process. 

The webinar included discussion on  some of the following topics:

  • In situations where a carrier/self-insured is changing Section 111 reporting companies: the new reporting company will use the same RRE number as its predecessor, but the carrier/self-insured should also coordinate this turnover with Medicare through their Electronic Data Interchange (EDI) representative. This can happen if a carrier/self-insured is changing Third Party Administrators (TPA) or Section 111 reporting vendor.
  • Currently, Medicare is performing certain “threshold checks” associated with a company’s Section 111 quarterly submissions: Delete transactions for more than 5% of the total records submitted, 20% or more of the total records failed, with a disposition code of “SP”, and TPOC amount or No-Fault Limit exceeds 100 million dollars
  • Medicare also reiterated that claims involving both PIP and Med Pay policies may need to report ORM under each policy depending on the claims circumstances. This allows Medicare to complete its searches associated with coverage.

The MMSEA Section 111 User Guide is Medicare’s comprehensive reference for Section 111 reporting.  This means most circumstances or questions involving Section 111 are covered in the user guide with Medicare’s recommendations.  If there are still questions after referring the user guide, an RRE can contact Medicare directly through their EDI representative or if non-responsive, Medicare’s Section 111 escalation process.

  • Accurate and Timely reporting of ORM and TPOC is paramount for Medicare’s search and collection.
  • ICD9 codes are not as specific as ICD10. If there are issues with claimant obtaining treatment for similar, but not same body part (i.e. left and right hands), updating these codes may have an impact.
  • Claims prior to 10/1/2015 can use ICD9 (however see above).
  • A settlement may need to use “NOINJ” as conditions alleged and released as a part of settlement but only in limited circumstances.

Medicare did not discuss the proposed civil monetary rule, but stated it was still in the rulemaking process and questions would be answered after the rule was published.  We will keep you posted as additional updated become available.   

CMS will be releasing the webinar and PowerPoint in the next several weeks and we will advise once the link is available. 

For further questions or for any of your Medicare compliance needs, please contact our Settlement Consulting Team at [email protected]